Intraoperative localization of parathyroid adenoma using 99Mtechnetium sestamibi

We herein illustrate an unusual but very helpful maneuver in the localization of parathyroid adenomas that have proven difficult to find at initial surgical exploration. This case also illustrates how metabolically active thyroid tumors can interfere with the localization of parathyroid tumors when using the technetium-thallium subtraction scan technique, and a possible way of overcoming such interference.

Effects of delayed processing on mammographic phantom object detection

OBJECTIVES

Delayed processing of films is a common occurrence in mobile mammography screening programs. The effects of such delayed processing on radiologists' detection of phantom test objects are investigated.

METHODS

Twelve screen-film combinations were exposed using a phantom and developed after delays of 0, 1, 2, 3, 5, and 7 days. Films were scored by three board-certified radiologists specializing in mammography, based on visibility of calcifications, masses, fibrils, and line pairs.

RESULTS

Variance analyses of mean scores indicate that, across screen-film combinations, there are no statistically significant decreases in object detection associated with delayed processing. The analyses do indicate, however, a statistically significant difference in scores unrelated to delay, attributable to the screen-film combination used.

CONCLUSIONS

Delayed processing of mammography film does not lead to a decrease in the visibility of phantom test objects, despite large decreases in overall image optical density.

Emergency nurses' perceptions of critical incidents and stress debriefing

INTRODUCTION

This is a descriptive study of questionnaire responses of 682 members of three state ENAs, with supporting interview data from 26 of those participants. The objective was to determine (1) the types of clinical events perceived as critical and (2) the usefulness of critical incident stress debriefings for emergency nurses.

METHODS

Questionnaires asking emergency nurses to rate clinical incidents as critical and to respond to questions about their experiences with debriefings were sent to members of three state ENAs. Structured interviews about personal experiences with critical incidents and debriefings were conducted with 26 respondents.

RESULTS

Emergency nurses responding to the questionnaire viewed the death of a child and the death of a coworker as the most critical of the possible events. The majority of interviewees saw an incident related to the death of a child as the most critical in their careers. Of the questionnaire respondents, 32% had participated in debriefings; 88% of those found them helpful in reducing critical incident stress.

DISCUSSION

The findings suggest that managers should be alerted to the possibility of acute stress responses when emergency nurses experience a child's death. Education regarding stress and debriefings may be helpful to ED personnel.

Using a comprehensive taxonomy of diagnoses to describe the practice of pediatric nurse practitioners: findings of a field study

The goal of this study was to develop and field test a classification of diagnoses for use by pediatric nurse practitioners. A secondary goal was to describe the clinical practice of pediatric nurse practitioners in a way using a classification that integrates medical, nursing, and developmental diagnoses. Six pediatric nurse practitioners were oriented to the system, established interrater reliability, and then used the system to record their diagnoses for 240 consecutive patients each. The pediatric nurse practitioners used more than 3000 diagnoses with 1450 cases. Their scope of practice included 1% developmental problems, 72% pediatric diseases, which included 51% illnesses and 21% disease prevention and screening, and 27% daily living problems. Pediatric nurse practitioner coders evaluated the system in positive terms. Issues related to the use of a taxonomy such as this one for practicing clinicians were discussed.

New diagnosis: caregiver role strain

Caregiver role strain is a new diagnosis accepted by NANDA in 1992. The diagnosis is a well-described family phenomenon that can be measured and predicted. Sources of variance for the various defining characteristics have been identified. The diagnosis is also important to society. Nurses can play a significant part in reducing the role strain caregivers feel or preventing its occurrence.

Evaluation of needs of high- and low-income families following paediatric traumatic brain injury

This paper assesses the needs of high- and low-income caregivers shortly after the traumatic brain injury of their child. The Family Needs Questionnaire [1], developed to assess the priorities and satisfaction of needs among family members, was administered to 49 caregivers. Surprisingly, caregivers from both groups displayed similar patterns of priorities and rated their most important needs as met. Caregivers' most important needs included clear information, therapy input, and understanding from professionals and classroom teachers. Personal needs, family support, and future patient-related concerns were devalued by both groups. These results are discussed as having implications for identification of high-risk families, treatment goals, and community reintegration needs.

Activation of human peripheral blood T lymphocytes by pharmacological induction of protein-tyrosine phosphorylation

Protein-tyrosine kinase and protein-tyrosine phosphatase (PTPase) activities are essential for T-cell antigen receptor-mediated signaling. To assess the functional consequences of alteration of the levels of tyrosine phosphorylation in normal human T cells, the effects of vanadate and hydrogen peroxide were studied. In combination, these agents induced tyrosine phosphorylation of cellular substrates, elevated cytosolic free calcium, and induced interleukin 2 receptor (IL-2R) alpha chain expression but not IL-2 secretion. However, anti-CD28 antibody in combination with vanadate and hydrogen peroxide induced IL-2 secretion, consistent with the requirement for a costimulatory signal in the induction of this gene. The effects of vanadate and hydrogen peroxide were enhanced in the absence of the T-cell PTPase, CD45. Thus, acute pharmacologic manipulation of the level of tyrosine phosphorylation in normal T cells correlates with partial, but not full, activation of these cells; in concert with a costimulatory signal provided by perturbation of the CD28 molecule, the complete program of activation is initiated. These agents should prove useful in dissecting signaling pathways involved in the regulation of genes critical to the immune response.

Pharmacological management of cancer pain. A guide for the health care professional

Cancer pain continues to remain a significant problem for oncology patients treated in both the university and the community setting. Nursing knowledge regarding pain management has advanced significantly in recent years. This article provides health care professionals with current factual information on cancer pain management. The information focuses on the emotional aspects of cancer pain, specific principles of analgesic management, opioid equianalgesics, multiple approaches to opioid administration, management of unwanted side effects, and a description of inappropriate drug therapies.

Reducing children's pain-distress associated with injections using cold: a pilot study

This study used an experimental design to test the question, "Does ice reduce the pain-distress children experience with injections?" One half of the 38 preschool children had ice applied to the preimmunization site for 30 seconds. The remaining children received the injection without the extra intervention. Measures included the Global Mood Scale, pulse rate, Oucher scale, and Faces scale. The results failed to show that ice reduces children's pain-distress with injections. Reasons for the failure are discussed, with comments on the various measures and suggestions for further study in this area of child nursing care.

A new assessment model and tool for pediatric nurse practitioners

This article presents a comprehensive assessment model for pediatric nurse practitioner (PNP) practice that integrates familiar elements of the classical medical history, Gordon's Functional Health Patterns, and developmental fields into one system. This model drives the diagnostic reasoning process toward consideration of a broad range of disease, daily living (nursing diagnosis), and developmental diagnoses, which represents PNP practice better than the medical model does.

Isolated significant left main coronary artery stenosis: angiographic, hemodynamic, and clinical findings in 16 patients

Among 21,545 adult patients who underwent consecutive coronary angiography, 16 (0.07%) were found during their coronary arteriography to have a significant isolated stenotic lesion (luminal diameter narrowing of 50% or more) located at the left main coronary artery. The remaining major epicardial coronary arteries and their branches were free of disease. A strong predilection for the isolated lesion to occur at the ostium of the left main artery was found (12 patients). The most common presenting symptom was angina of less than 4 weeks' duration, although one third of the group was asymptomatic. Resting electrocardiograms were normal in 12 patients, while three patients had T wave inversion and another had nonspecific ST-T changes. Eleven patients exhibited severe stenosis, with eight having 70% to 89% stenosis and three having 90% to 95% stenosis. Five patients had 50% to 69% stenosis. No significant differences were found between patients with angina and patients without angina with respect to age, left ventricular end-diastolic pressure, left ventricular ejection fraction, and mean percent stenosis of the obstructive lesion. Despite the severity and the crucial location of the obstructive lesion, most patients with an isolated, significant left main stenosis appear to have a preserved left ventricular ejection fraction, normal wall motion, and no significant alteration of the left ventricular end-diastolic pressure.

Parallels between research and diagnosis: the reliability and validity issues of clinical practice

There are many similarities between the methods used to conduct research and the strategies clinicians utilize to improve the quality of the data collected for diagnostic purposes. This article reviews basic reliability and validity issues as they relate to clinical practice.

Development and content validity testing of a comprehensive classification of diagnoses for pediatric nurse practitioners

Pediatric nurse practitioners (PNPs) need an integrated, comprehensive classification that includes nursing, disease, and developmental diagnoses to effectively describe their practice. No such classification exists. Further, methodologic studies to help evaluate the content validity of any nursing taxonomy are unavailable. A conceptual framework was derived. Then 178 diagnoses from the North American Nursing Diagnosis Association (NANDA) 1986 list, selected diagnoses from the International Classification of Diseases, the Diagnostic and Statistical Manual, Third Revision, and others were selected. This framework identified and listed, with definitions, three domains of diagnoses: Developmental Problems, Diseases, and Daily Living Problems. The diagnoses were ranked using a 4-point scale (4 = highly related to 1 = not related) and were placed into the three domains. The rating scale was assigned by a panel of eight expert pediatric nurses. Diagnoses that were assigned to the Daily Living Problems domain were then sorted into the 11 Functional Health patterns described by Gordon (1987). Reliability was measured using proportions of agreement and Kappas. Content validity of the groups created was measured using indices of content validity and average congruency percentages. The experts used a new method to sort the diagnoses in a new way that decreased overlaps among the domains. The Developmental and Disease domains were judged reliable and valid. The Daily Living domain of nursing diagnoses showed marginally acceptable validity with acceptable reliability. Six Functional Health Patterns were judged reliable and valid, mixed results were determined for four categories, and the Coping/Stress Tolerance category was judged reliable but not valid using either test. There were considerable differences between the panel's, Gordon's (1987), and NANDA's clustering of NANDA diagnoses. This study defines the diagnostic practice of nurses from a holistic, patient-centered perspective. It is the first study to use quantitative methods to test a diagnostic classification system for nursing. The classification model could also be adapted for other nurse specialties.

The contribution of medical nitrous oxide to the greenhouse effect

Nitrous oxide is now recognised as an important contributor to the 'greenhouse' effect. Each year the medical profession unwittingly adds a very small burden of this gas to the atmosphere. Unfortunately, the long lifetime of nitrous oxide means that all emissions into the atmosphere are significant. By making small changes in their practices, anaesthetists are well-placed to help reduce the potential environmental damage.

Effect of heat inactivation of HIV on specific serum proteins and tumour markers

The effect on the concentrations of specific serum proteins and tumour markers, of heat-treating samples at 56 degrees C for 30 min to inactivate HIV, was investigated. Statistically significant decreases, that may affect clinical decisions, were observed for alpha-1-antitrypsin, beta-2-microglobulin, IgE, fibrinogen, C1-esterase inhibitor and CA125. Statistical, but not clinically significant, changes were observed for alpha-1-acid glycoprotein, C3, haptoglobin, IgA, IgG, IgM and transferrin. A significant decrease in the alpha-1 band was observed on protein electrophoresis.

Low-dose oral administration of human interferon alpha can control the development of Theileria parva infection in cattle

Two natural human interferon alpha preparations, (nHuIFN-alpha [Cantell]) and (nHuIFN-alpha [ISI]), were used for the oral treatment of cattle experimentally infected with Theileria parva parva. In the first experiment, 8 Friesian bulls were inoculated with a 1 in 10 dilution of a sporozoite stabilate of T.p. parva (Marikebuni) stock. Four of the cattle were treated daily with 1 international unit/kg body weight (i.u./kg bwt) of nHuIFN-alpha (Cantell) from day -2 to day 8 p.i. None of the 4 calves given IFN developed clinical theileriosis, but 3 of the 4 control calves died of theileriosis while the fourth had a mild infection. Three of 4 treated calves and the 1 surviving control calf developed a detectable antibody response to T.p. parva schizont antigen but, on challenged with a 10-fold higher dose of stabilate, the surviving control animal and only 1 of the 4 treated calves proved to be immune. In a second experiment, 4 groups of 4 calves were inoculated with the same stabilate dilution. Three treatment groups were given either 1 i.u. nHuIFN-alpha (Cantell), 1 i.u. nHuIFN-alpha (ISI), or 10 i.u. nHuIFN-alpha (ISI)/kg bwt from day -2 to day 8 p.i. once daily and the fourth group were controls. Clinical theileriosis occurred in 2 controls, 2 calves given 10 i.u. nHuINF-alpha (ISI), 1 calf given 1 i.u. nHuIFN-alpha (ISI) and no calves given 1 i.u. nHuIFN-alpha (Cantell)/kg bwt. Of these, 2, 1, 0 and 0 cattle died in the respective groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Biological actions of 53 kDa nerve growth factor as studied by a blot and culture technique

A blot and culture technique has been utilized to examine the biological actions of 53,000 Dalton (53 kDa) nerve growth factor (NGF) present in the submaxillary gland (SMG) of adult male and female mice. SMG-proteins were first resolved by sodium dodecylsulfate (SDS) polyacrylamide gel electrophoresis (PAGE) under reducing conditions and then transferred to a nitrocellulose (NTC) sheet by electroblotting. Specific areas corresponding to 53 kDa NGF were cut and cultured with the rat pheochromocytoma cell line, PC-12. NTC strips bearing the 53 kDa NGF band stimulated cell flattening and neurite formation in serum containing growth medium and augmented cell survival in serum-free growth medium. Similar results were obtained with NTC strips bearing the 13 kDa NGF band. The results suggest that 53 kDa NGF, like 13 kDa NGF, exerts both tropic and trophic actions on its target neurons.

Molecular forms of nerve growth factor in mouse submaxillary glands

By use of immunoblot analysis, we demonstrate the presence of a nerve growth factor with a relative molecular mass (Mr) of 53,000 in submaxillary glands of adult male and female mice in addition to the 13,000 form previously discovered in this tissue. Both the Mr 53,000 and 13,000 forms of nerve growth factor are present at equal concentrations in salivary glands of male mice while the Mr 53,000 form is present at a greater concentration than the Mr 13,000 form in the glands of female mice. Testosterone pretreatment, however, specifically augments the Mr 13,000 form of nerve growth factor in the salivary glands of female mice. The existence of nerve growth factor with molecular weight of 53,000, which is higher than the molecular size predicted for the two precursor forms of nerve growth factor, suggest the possibility that one of the nerve growth factor precursors or a product derived from it may undergo post-translational modification in submaxillary glands of mice.

Pancreatic exocrine and endocrine function after subtotal pancreatectomy for nesidioblastosis

Pancreatic exocrine and endocrine function was assessed in seven patients 1 to 2 years after 95% pancreatectomy (group A) and three patients 9 to 11 years after 75% pancreatectomy (group B). In all cases surgery was undertaken for the treatment of hyperinsulinism and the histologic diagnosis was nesidioblastosis. The activities of pancreatic enzymes and bicarbonate concentrations were generally normal in group B, but were reduced in approximately half the children in group A. One child in group A had significant exocrine failure and poor weight gain. Blood glucose levels and fasting insulin levels were normal during a standard glucose tolerance test in all of the group B patients. One had a low fasting blood glucose level. In the group A patients three had low fasting glucose levels and one a frankly diabetic glucose tolerance test. C peptide and insulin levels were comparable but inappropriate insulin levels were noted in one patient, suggesting that the control of glucose-stimulated insulin release may remain abnormal. The results suggest that pancreatic function is not seriously impaired in the majority of patients 1 to 2 years after 95% pancreatectomy and that it is comparable to that noted in 75% pancreatectomy patients followed over a longer period of time.

Neisseria meningitidis in a primary school

A prospective study of the nasopharyngeal carriage of sulphonamide resistant Neisseria meningitidis, group B, type 15 P1.16, was undertaken after a cluster of four cases of meningococcal infections had occurred, two of which were fatal, during a three year period among children attending an inner London primary school. Throughout the year of the study the overall carriage and acquisition rates of meningococci were less than 6% and 1%, respectively, and were no different from those of control children of similar age and ethnic origin from another school. The outbreak strain was isolated from three children in the study school, however, but from none in the control school. A comparison of bactericidal activity in serum against the outbreak strain in children from selected classes in each school showed that there was no lack of bactericidal activity to this strain in the study school. The low prevalence of strain specific bactericidal activity in sera taken from classroom contacts of carriers, combined with the low carriage and acquisition rats, suggested a pattern of prolonged colonisation with infrequent transmission of the organism from child to child, and was consistent with the pattern of cases seen in the school.

Analysis of the effect of a sunscreen agent on the suppression of natural killer cell activity induced in human subjects by radiation from solarium lamps

Previous studies in rodents have shown that ultraviolet radiation (UVR) may have direct effects on the immune system in the skin and at higher doses may induce systemic suppression of immune responses. We have previously shown that UVR from sun or solarium beds may induce systemic effects in human subjects. The purpose of the present study was to examine whether these systemic effects in human subjects could be prevented by use of commercially available sunscreen agents. Groups of 12 normal subjects were exposed to radiation from solarium lamps after application of a sunscreen agent or the base used in its preparation. Twelve half-hourly exposures induced a depression of natural killer (NK) cell activity against a melanoma and the K562 target cell which was not prevented by use of the sunscreen agent. Changes in functional activity were accompanied by a reduction in NK cell numbers assessed by Leu-11 monoclonal antibodies against the labile Fc receptor. Application of the sunscreen agent also did not protect against effects of solarium exposure on recall antigen skin tests and immunoglobulin production in vitro in pokeweed mitogen-stimulated cultures of B and T cells. These results suggest that further evaluation of the wave-length spectrum of UVR and the effectiveness of sunscreen agents in prevention of UVR-induced effects on the immune system is needed.

Adrenal hemangioblastoma in Von Hippel-Lindau disease as a cause of secondary erythrocytosis

Von Hippel-Lindau disease (VHLD) is an inherited disorder with protean manifestations including tumors that may cause secondary erythrocytosis: cerebellar hemangioblastoma, renal cell carcinoma, and pheochromocytoma. The case of a woman with VHLD whose secondary erythrocytosis resolved after removal of an adrenal hemangioblastoma is reported. This is the first reported case of adrenal hemangioblastoma in VHLD. Furthermore, it appears that adrenal hemangioblastoma is a cause of secondary erythrocytosis.

Enhancement of cytotoxic and proliferative responses of lymphocytes from melanoma patients by incubation with monoclonal antibodies against ganglioside GD3

Previous studies have shown that monoclonal antibodies (M.Ab) to the ganglioside GD3 may induce partial remissions in tumour growth in patients with melanoma. In vitro studies demonstrated that M.Abs to GD3 may also enhance lymphocyte responses to phytohemagglutinin and interleukin 2 (IL2). The present study extended these findings by showing that the IL2-dependent proliferative and cytotoxic response of T cell clones derived from a melanoma patient and a patient with the Vogt-Koyanagi-Harada syndrome were enhanced by pre-incubation of T cells with M.Ab to GD3. The degree of enhancement increased with the duration of pre-incubation from 2 to 24 h and applied to both T4+ and T8+ clones. The potentiation of these responses was not specific for M.Abs to GD3 but was also seen with M.Abs to GD2 and the T10 structure on T cells but not with M.Abs to the transferrin receptor or an isotype control M.Ab. Incubation of lymphocytes from a melanoma patient with M.Ab to GD3 during culture with autologous melanoma cells enhanced the proliferative response to the tumour. The expression of IL2 receptors (Tac epitope) on the T cells showed variable enhancement after incubation with M.Ab to GD3 but the significance of these findings in relation to the mechanism of the enhanced responses is not known. These results suggest that certain M.Abs may stimulate cell-mediated immune responses against tumour cells and that this may provide an additional mode of action of M.Abs against tumours in vivo.

Potentiation of lymphocyte responses by monoclonal antibodies to the ganglioside GD3

Previous studies have shown that the ganglioside GD3 is expressed in high concentrations on melanoma cells and that monoclonal antibodies (MAbs) against GD3 may induce partial remissions in tumor growth in patients with melanoma. The present studies indicated that incubation of interleukin 2 (IL2) dependent murine natural killer cells with several MAbs against the ganglioside GD3 potentiated the proliferative response to IL2. There was no effect on cell division in the absence of added IL2. Similarly the mitogenic response of human blood lymphocytes to phytohemagglutinin (PHA) or the T3 antigen was enhanced by coculture with these MAbs. This was noted when the MAbs to GD3 were added either before or up to 48 h after addition of PHA or MAb to T3. Kinetic analysis revealed that the potentiation of the PHA induced mitogenic response followed the expected response to PHA suggesting that the MAbs amplified normal activation pathways. These effects were also seen wih MAb to GD3 and the T10 structure on T-cells but not with MAbs to the transferrin receptor or isotype MAb controls. Studies on T-cell subsets suggested that the enhanced PHA responses were confined mainly to the T8 subset and responses of the T4 subset were not enhanced. Flow cytometric analysis revealed low levels of GD3 expression on blood lymphocytes which increased during culture with PHA. IL2 receptor (Tac epitope) expression did not show close correlation with the enhanced lymphocyte responses and the mechanism of the potentiation remains uncertain. These studies raise questions concerning the role of gangliosides in T-cell activation and whether these in vitro effects of MAbs to GD3 may account in part for their antitumor effects in patients with melanoma.

The Inventory for Depressive Symptomatology (IDS): preliminary findings

The Inventory for Depressive Symptomatology (IDS) is a new measure of depressive signs and symptoms. Both self-report and clinician-rated versions are under development. The IDS-SR (self-report) was completed by 289 patients, 285 of whom were outpatients. Unipolar major depression (n = 174), bipolar disorder (n = 44), euthymic (S/P unipolar or bipolar) depression (n = 33), and other psychiatric disorders (n = 38) were included. The IDS-SR had good internal reliability (coefficient alpha = 0.85), and significantly correlated with both the Hamilton Rating Scale for Depression (HRSD) (r = 0.67) and the Beck Depression Inventory (BDI) (r = 0.78). The clinician-rated IDS (IDS-C) was administered to 82 outpatients (75 with unipolar or bipolar disorder, 5 with other psychiatric disorders, and 2 euthymic (S/P unipolar) depressions). Coefficient alpha (0.88) suggested strong internal consistency. The IDS-C correlated highly with both the HRSD (r = 0.92) and the BDI (r = 0.61). Discriminant and factor analyses provided evidence for construct validity for both the IDS-C and IDS-SR. Both scales significantly differentiated endogenous from nonendogenous depression defined by Research Diagnostic Criteria (RDC). Factor structures for the IDS-SR revealed four factors: mood/cognition, anxiety, selected endogenous symptoms, and hyperphagia-hypersomnia. The IDS appears applicable to both inpatients and outpatients with endogenous, atypical, and nonendogenous major depression, and may have utility with dysthymics.

Clonal analysis of cytotoxic T lymphocytes (CTL) against autologous melanoma. Classification based on phenotype, specificity and inhibition by monoclonal antibodies to T cell structures

This study investigates the nature and specificity of cytotoxic T lymphocytes (CTL) in patients with melanoma which are able to kill autologous melanoma cells. Interleukin 2 (IL2)-dependent T cell clones from two melanoma patients and a normal subject were generated in mixed lymphocyte cultures (MLC) or mixed lymphocyte tumor cell cultures (MLTC) and propagated for prolonged periods in tissue culture. Analysis of their phenotype by a wide range of monoclonal antibodies (M.Abs) revealed two main phenotypes which depended on whether they expressed Fc receptors detected by Leu 11 M.Abs or not. Leu 11- T cells (referred to as Type 1) were inhibited by M.Abs to T3, T8, and a common HLA, ABC antigen. Conversely Leu 11+ T cells (referred to as Type 2) were inhibited by M.Ab to Leu 11 but not by M.Ab to T3, T8 and the HLA, ABC antigen. Subtypes among Type 1 cells were recognized which depended on their specificity. The most restricted were CTL [Type 1(a)] clones generated only in MLTC which recognized the autologous melanoma cell plus 1 of 11 other melanoma target cells. Type 1(b) CTL clones recognized a larger proportion (approximately 50%) of the melanoma cells. A third category [Type 1(c)] recognized antigens on melanoma cells shared with that on the EBV-transformed B cells used as stimulators in the MLC. Type 2 CTL clones had broad specificity to melanoma and nonmelanoma cells, characteristic of that described for lymphokine activated killer (LAK) cells. The latter were MHC unrestricted but further studies are required to clarify whether the Type 1 CTL clones are MHC restricted or not. The CTL activity of all clones was inhibited by M.Ab to the sheep red blood cell receptor and to the T10 antigens. It is suggested that recognition of these different types of CTL clones may assist future studies on the immune response against melanoma and the nature of antigens recognized by CTL.

Smoking in hospital--a survey of staff attitudes at Westminster Hospital

A survey of staff attitudes to smoking and facilities for smokers and non-smokers at Westminster Hospital and associated buildings revealed widespread support for firmer measures to limit and control smoking on health service premises. The survey was eventually undertaken with the agreement of staff side union representatives who had initially resisted the health authority's wish to implement a policy on smoking. In the event, the results provided support to the TUC's 1981 Resolution calling for increased smoking restrictions in workplaces as part of an overall policy to reduce smoking prevalence among working people, which has been followed up in local initiatives by unions throughout the country.

Familial hypocalciuric hypercalcaemia: association with neonatal primary hyperparathyroidism, and possible linkage with HLA haplotype

A kindred is described, six members of which fulfilled criteria for the syndrome of familial hypocalciuric hypercalcaemia (FHH). The majority of these individuals were asymptomatic: their hypercalcaemia was revealed by biochemical screening after parathyroid surgery had failed to diminish the elevated serum calcium concentration of the index case. In contrast to those members of the family diagnosed as adults, the daughter subsequently born to the index case included in her expression of FHH clinical features of severe neonatal primary hyperparathyroidism. Four hyperplastic parathyroid glands were excised, and following surgical intervention the baby improved clinically and accelerated the healing of her skeletal lesions. Her case suggests that an association does exist between FHH and neonatal primary hyperparathyroidism. Of the ten individuals at risk, inheritance of hypocalciuric hypercalcaemia was paralleled in eight cases by inheritance of the HLA haplotype All BW55 CW3 DR4. Such possible linkage has not previously been reported.

The thinker-doer dual nursing role

Nursing, for a time, was a profession polarized into "thinker" and "doer" groups. This polarization was bridged by nurse practitioners who were expected to be both knowledgeable and capable; the degree of their accountability demanded both. More recently, the nursing world has come to accept the duality of the thinker-doer nursing role. It is no longer unthinkable for a clinically oriented journal to discuss practice-relevant theories. Theories can be viewed as generalizations which guide decision making. They don't have to be grand theories which encompass every human condition to be valuable. In this series, advantages and disadvantages of a number of practice-relevant theories will be explored. Early on, "borrowed" theories will be considered. Later, some newer, more original theories will be discussed.

Heterochromatic polymorphism in spontaneous abortions

Since the advent of C-banding as a routine diagnostic procedure, the significance of heterochromatic polymorphism has been questioned. Some workers have considered variations in heterochromatin in chromosomes 1 and 9 to be associated with fetal wastage, recurrent abortions, and abnormal phenotypes. Over a 15-month period, this laboratory made a study of the diagnostic significance of heterochromatic variants in 50 couples with a history of recurrent abortions. A control group of 50 couples with at least two normal children and no miscarriages was investigated simultaneously. The results indicated no significant difference in the heterochromatic regions between aborting and non-aborting couples.